Question

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of following statements should the nurse include?

Answer 1

Correct Answers:

"You will have a stoma in your left lower abdomen."

Rationale :

🔷 A sigmoid colostomy is typically placed in the left lower quadrant, as it connects to the sigmoid portion of the colon.

🔷 It produces formed stool, unlike ileostomies which produce liquid or pasty output.

🔷 A healthy stoma should appear pink or red and moist, not purple (which indicates ischemia).

🔷 Post-op pain is common around the surgical site, but the stoma itself is not painful, as it has no nerve endings.

🔷 Teaching the exact location prepares the client for visualization, self-care, and appliance positioning.

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Answer 2

Correct Answers:

An elevated A transglutaminase antibody (tTG-lgA) blood test

Rationale :

🟣 The tTG-IgA test is the most sensitive and specific marker for celiac disease. 🟣 This test detects autoimmune response to gluten, which damages intestinal villi. 🟣 It is commonly elevated before biopsy confirmation of the disease. 🟣 Other options are associated with thyroid or autoimmune conditions, not celiac disease. 🟣 The test is essential for initial screening and monitoring dietary compliance.

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Answer 3

Correct Answers:

Reduce the client's intake of protein.

Rationale :

💠 In hepatic encephalopathy, the liver cannot metabolize ammonia, which builds up from protein.

💠 Reducing protein intake temporarily helps decrease serum ammonia levels.

💠 Protein restriction is used along with medications like lactulose or rifaximin.

💠 Diuretics and vitamin K are used in other cirrhosis complications, not for ammonia reduction.

💠 Close monitoring helps prevent neurological decline and coma in these clients.

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Answer 4

Correct Answers:

Cirrhosis

Rationale :

🔶 Cirrhosis impairs liver function, causing low clotting factors and thrombocytopenia, leading to bruising and bleeding.

🔶 Frequent nosebleeds and bruises are signs of decreased platelet and clotting activity.

🔶 Alcohol use is a major risk factor for cirrhosis development.

🔶 The liver normally synthesizes vitamin K-dependent clotting proteins, which are reduced in cirrhosis.

🔶 These symptoms should prompt evaluation of coagulation labs and liver function.

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Answer 5

Correct Answers:

Limit 1M injections.

Rationale :

✔ With a platelet count of 130,000/mm³, the client is at increased bleeding risk, especially from trauma like IM injections.

✔ IM injections can cause hematomas, which can be difficult to control.

✔ Alternative oral or subcutaneous routes should be preferred.

✔ The nurse should also monitor bleeding sites and gums regularly.

✔ Avoiding rectal temps and rough handling further minimizes risk.

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Answer 6

Correct Answers:

"Coming into contact with infected blood, such as from that of a ditty needle, can cause you to become infected with hepatitis C."

Rationale :

🔵 Hepatitis C is primarily transmitted through blood-to-blood contact.

🔵 Sharing needles or exposure to infected blood products are major transmission routes.

🔵 It is not transmitted through saliva, food, or alcohol use.

🔵 Risk reduction includes avoiding needle sharing and proper blood screening.

🔵 Education is essential for preventing further spread and long-term liver damage.

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Answer 7

Correct Answers:

Empty the pouch when it is 1/2 full.

Rationale :

🟢 Allowing the pouch to overfill increases the risk of leakage, skin irritation, and appliance detachment.

🟢 ½ full is the standard for optimal emptying to ensure comfort and function.

🟢 Firm stool is not expected in an ileostomy—output is typically liquid to semi-liquid.

🟢 Cleaning the peristomal area 1–2 times daily is sufficient; overcleaning can irritate the skin.

🟢 Proper pouch maintenance prevents embarrassment and promotes confidence.

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Answer 8

Correct Answers:

Withhold oral fluids and food.

Rationale :

🔴 In acute pancreatitis, the pancreas is inflamed and must be rested to prevent enzyme release.

🔴 NPO status is critical to reduce pancreatic stimulation and decrease pain.

🔴 Other interventions are important but not the immediate priority.

🔴 Pain control comes first, followed by GI rest and IV hydration.

🔴 Early refeeding can worsen inflammation and cause complications.

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Answer 9

Correct Answers:

Spider angiomas

Rationale :

🟠 Spider angiomas are telangiectasias associated with liver dysfunction, particularly cirrhosis.

🟠 They result from elevated estrogen levels due to impaired liver metabolism.

🟠 Other findings in cirrhosis include jaundice, ascites, and palmar erythema.

🟠 Tarry stools may suggest GI bleeding, not a typical early cirrhosis sign.

🟠 Their presence helps in non-invasive assessment of chronic liver disease.

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Answer 10

Correct Answers:

Frequent handwashing
Visiting the eye doctor annually
Joining a support group

Rationale :

✳️ Handwashing reduces infection risk, which is critical in sickle cell clients prone to crises.

✳️ Eye exams detect complications like retinopathy, common in sickle cell disease.

✳️ Support groups help with emotional and social coping, improving quality of life.

✳️ Annual flu vaccines are recommended—not avoiding them.

✳️ Iron supplementation is not routine unless iron-deficiency anemia coexists.

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RN Custom N202 Test 3~2025.

No.

1 :
A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of following statements should the nurse include?

2 :
A nurse is reviewing the plan of care for a child who was recently diagnosed with celiac disease. Which of the following laboratory results should the nurse expect?

3 :
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

4 :
A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions?

5 :
A nurse is planning care for a client who has leukemia and a platelet count of 130.000/mm3. Which of the following interventions should the nurse include in the plan of care?

6 :
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?

7 :
A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain. which of the following should the nurse address as the priority intervention?

9 :
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

10 :
A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching? (Select All that Apply.)

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RN Custom N202 Test 3~2025.

No.

1 : A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of following statements should the nurse include?

2 : A nurse is reviewing the plan of care for a child who was recently diagnosed with celiac disease. Which of the following laboratory results should the nurse expect?

3 : A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

4 : A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions?

5 : A nurse is planning care for a client who has leukemia and a platelet count of 130.000/mm3. Which of the following interventions should the nurse include in the plan of care?

6 : A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?

7 : A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include?

8 : A nurse is caring for a client who has acute pancreatitis. After treating the client's pain. which of the following should the nurse address as the priority intervention?

9 : A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

10 : A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching? (Select All that Apply.)

1 :
A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of following statements should the nurse include?

2 :
A nurse is reviewing the plan of care for a child who was recently diagnosed with celiac disease. Which of the following laboratory results should the nurse expect?

3 :
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

4 :
A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions?

5 :
A nurse is planning care for a client who has leukemia and a platelet count of 130.000/mm3. Which of the following interventions should the nurse include in the plan of care?

6 :
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?

7 :
A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain. which of the following should the nurse address as the priority intervention?

9 :
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

10 :
A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching? (Select All that Apply.)